Controlled substance education
Controlled substances are drugs that have potential for abuse. These are regulated by the federal Controlled Substance Act (CSA).
CSA helps to monitor medications for pain, particularly opioids, medications for anxiety, insomnia, sedatives, hypnotics, or anxiolytics. Medications for central nervous system stimulation such as those for ADD, ADHD and narcolepsy.
Acute pain is:
Good treatment of acute pain is necessary to
Acute pain recommendations:
Utah's controlled substance database will/can be used for the management of patients medications.
You and your provider should consider risks of opioid treatment before initiating trial and use screening tools to determine patients with concern.
Risk factors for consideration include:
Your providers recommendations on Short-acting opioids:
Patient education:
Patients should be educated on safe use of opioid/narcotics, potential adverse effects, dangers when combining with depressants (including antidepressants, sleep aids, sedatives, or alcohol) before taking any narcotic medications. This can be given by your provider, your pharmacist, on your prescription information, or reputable sites online. Make sure to discuss these with your provider/pharmacist and pay attention so that appropriate questions can be answered.
What if my pain persists longer than expected?
Your provider will reevaluate opioid use when pain persists beyond the expected time period. Evaluation of the level of patients pain during mobility or activity is used to determine accurate pain control.
Your provider will help to determine the reason for persistent pain and if needed consider chronic pain management, and establish a plan for transitioning to a more effective and safe treatment medication or pain management provider.
Acute pain advancing to chronic pain: Most chronic pain begins from acute pain.
The pathophysiology of chronic pain suggest that in the presence of severe nociceptive activation, persistent inflammation and ronnel damage, centralization sensitization emerges and causes nerve are remodeling. In this situation, reversible modulation begins to deteriorate into a irreversible modification.
Risk factors in the advancement from acute pain and chronic pain.
Risk factors for abuse include:
Major medical risks of using narcotic medications include:
Opioid treatment may be indicated when the following criteria is met:
A patient will only be written a prescription for a controlled substance when:
Agreements include:
Patient should be thoroughly educated by providers, pharmacists in:
Tracking tools used by providers and patients to ascertain if treatment goals are being met include:
Physician will assess treatment success or failure based off of improvement in function and pain relief and document appropriate treatments as needed. Continual evaluation for misuse or abuse of medications and failure to comply with the treatment agreement will be performed. If felt appropriate employment of risk reduction strategies will be performed including implementing screening and monitoring processes.
Screening tools to determine patients compliance include:
the American pain Society and American Academy of pain medicine recommend routine urine screening for all patients.
Screening tests including laboratory tests screen for:
The 6 A's of drug abuse behavior include:
Reason to refer the patient to a pain management specialist:
A multidisciplinary approach for pain shows a better outcome including:
Subacute or chronic pain is often:
Multidisciplinary approach team may include:
Functional outcome and treatment discontinuation:
Discontinuation is of pain medication often needs to be performed in a decreasing tapered fashion. This may be performed by reducing the opioid dose by 25% per week. Rapid decrease may cause withdrawal symptoms including:
Withdrawal risks higher with longer treatment and higher doses.
Summary:
CSA helps to monitor medications for pain, particularly opioids, medications for anxiety, insomnia, sedatives, hypnotics, or anxiolytics. Medications for central nervous system stimulation such as those for ADD, ADHD and narcolepsy.
Acute pain is:
- Pain lasting a short duration from days to weeks.
- Pain that also has a clear pathologic explanation such as injury or surgery.
- Pain that improves as pathology resolves.
- Pain can range from mild to severe.
Good treatment of acute pain is necessary to
- maintain function
- improve mobility
- maintain respiratory function
- reduce post injury or surgical complications.
Acute pain recommendations:
- use narcotics to treat acute pain only when moderate – severe.
- consider non-opioid pain medications and treatments for mild – moderate pain.
- weaker opioids or narcotics are preferred.
- consider other pain relieving techniques such as ice heat rest elevation or anti-inflammatories, physical therapy, exercise, meditation, stress relieving exercises etc.
- Local anesthetic or regional anesthetic as needed
Utah's controlled substance database will/can be used for the management of patients medications.
You and your provider should consider risks of opioid treatment before initiating trial and use screening tools to determine patients with concern.
Risk factors for consideration include:
- prior substance abuse
- current substance abuse
- a history of smoking or injecting drugs including marijuana
- depressant or sedating medication use including over-the-counter sleep aids.
- employment status (i.e. unemployed/underemployed)
- affective disorders, such as depression and anxiety
Your providers recommendations on Short-acting opioids:
- when using short-acting opioids (in the majority of cases) follow the mantra "start low, go slow" method.
- Use the lowest prescribed dosage likely to be effective
- your provider will not dispense more than the number of pills needed usually a 7 day prescribing dosage limit or less.
- you will be assessed for function, pain, and adverse effects to individualized care.
- Excessive medications are often used for nonmedical purposes contributing to on intentional deaths.
Patient education:
Patients should be educated on safe use of opioid/narcotics, potential adverse effects, dangers when combining with depressants (including antidepressants, sleep aids, sedatives, or alcohol) before taking any narcotic medications. This can be given by your provider, your pharmacist, on your prescription information, or reputable sites online. Make sure to discuss these with your provider/pharmacist and pay attention so that appropriate questions can be answered.
What if my pain persists longer than expected?
Your provider will reevaluate opioid use when pain persists beyond the expected time period. Evaluation of the level of patients pain during mobility or activity is used to determine accurate pain control.
Your provider will help to determine the reason for persistent pain and if needed consider chronic pain management, and establish a plan for transitioning to a more effective and safe treatment medication or pain management provider.
Acute pain advancing to chronic pain: Most chronic pain begins from acute pain.
The pathophysiology of chronic pain suggest that in the presence of severe nociceptive activation, persistent inflammation and ronnel damage, centralization sensitization emerges and causes nerve are remodeling. In this situation, reversible modulation begins to deteriorate into a irreversible modification.
Risk factors in the advancement from acute pain and chronic pain.
- Demographics indicating a poor health status
- severity of pain and duration starts to occur multiple sites
- psychological factors including depression anxiety anger fear and stress
- social factors including pain work and litigation.
Risk factors for abuse include:
- age less than 45
- males more likely to misuse and abuse
- females who have been sexually abused
- family history of alcohol or drug abuse
- personal history of substance abuse
- smoking or injecting drugs
- use of sedation drugs including benzodiazepines or over-the-counter sleep aids
- unemployment
- patients who have legal problems
- poor family support
- isolation
- using multiple providers
- obtaining concurrent controlled substance prescriptions
- obtaining prescriptions from multiple pharmacies/locations
- Sample forms of abuse risk tools include ORT SOA AP – are and COMM
Major medical risks of using narcotic medications include:
- sleep disorders involving obstructive or sleep apnea
- cardiac disorders
- major psychiatric disorders such as personality disorders, depression, anxiety, bipolar, PTSD.
Opioid treatment may be indicated when the following criteria is met:
- other treatments including nonopioid analgesics have been tried and found to be ineffective
- patients function is not maintained or increased due to pain
- opioid treatment is been determined to be more beneficial than harm
- pain is moderate to severe
- measurable treatment goals have been defined
- patient clearly understands the risks and benefits of opioid therapy
- patient consents to the treatment
A patient will only be written a prescription for a controlled substance when:
- accurate record information is obtained
- a written treatment pan with measurable goals including long-term and short-term therapy
- this will include functional goals and not just pain levels
- patients sign treatment agreement once I understand and agree on a treatment plan
- should document requirements for chronic pain management
Agreements include:
- goals of treatment between the patient and the physician
- periodic drug testing
- frequent appointment follow-ups
- procedures for medications refills
- reasons for stopping on opioid treatments
- potential changes in the course of therapy
- 's patient only having one pharmacy and one prescriber
- requirements for drug testing until counts
- when established this is reviewed regularly to evaluate therapy and impact on function
- determine continuation or cessation of opioid therapy
- the treatment plan is not intended to eliminate all pain
- for prolonged controlled substance management and informed consent including risks and benefits of opioid treatment, counseling by the physician on proper use, storage, and disposal of medications and in combination with the treatment agreement will be signed.
Patient should be thoroughly educated by providers, pharmacists in:
- instructions and recommendations on usage of the medication
- safe storage use and disposal of the medication
- signs of overdose and actions to take if overdose occurs
Tracking tools used by providers and patients to ascertain if treatment goals are being met include:
- pain assessment and documentation tool (PA DT)
- patient pain and medication tracking chart
- brief pain inventory (BPI)
- treatment agreement
- patient health questionnaire (PHQ 9)
Physician will assess treatment success or failure based off of improvement in function and pain relief and document appropriate treatments as needed. Continual evaluation for misuse or abuse of medications and failure to comply with the treatment agreement will be performed. If felt appropriate employment of risk reduction strategies will be performed including implementing screening and monitoring processes.
Screening tools to determine patients compliance include:
- screening tool forms listed above (ORT, SO APP – R, COM M forms)
- random laboratory tests
- screening studies
- random pill counts
- Utah's substance control database
- signed treatment agreements
the American pain Society and American Academy of pain medicine recommend routine urine screening for all patients.
Screening tests including laboratory tests screen for:
- Presence of illegal drugs
- unreported prescription medication
- unreported alcohol use
- absence of the patients prescribed medication which could indicate diversion or nonadherence
The 6 A's of drug abuse behavior include:
- change in Affect (mood or personality)
- Analgesia: complete pain relief or numbness
- reduced Activities of daily living
- Adverse effects
- and Aberrant drug-related behavior
- Reduced airway or increased sleep apnea
Reason to refer the patient to a pain management specialist:
- prescribers reach the limit what he or she feels comfortable prescribing for any reason.
- treatment needs a multidisciplinary approach
- pain has progressed to a complex level significant risk factors for abuse and addiction have been noted
A multidisciplinary approach for pain shows a better outcome including:
- reduction in pain
- substantially better functional restoration
- reduced healthcare cost
- higher return to work rates
- reduced disability cost
Subacute or chronic pain is often:
- not only physical but also
- biological
- social
- psychological
- and neurological
Multidisciplinary approach team may include:
- medical doctor
- nursing
- physical therapy
- pharmacy
- psychology
- social work
Functional outcome and treatment discontinuation:
- failure to maintain improvement, regardless of reported pain relief, is a cause for stopping opioid therapy
- patient is documented to not have improvement in function despite increasing opioid dose or frequency may be an indicator of a nonresponse to opioids
- nonresponse to one opioid often means nonresponse to other opioids (examples myofascial pain and fibromyalgia)
- when opioids initially are effective but only remain effective with frequent increase in dose may be an indication that it is only addressing mood or anxiety and not pain. This is an inappropriate indication for opioids and the prescriber will discontinue treatment
- cause of pain has been resolved or reduced
- adverse effects outweigh the benefits
- dangerous or illegal behaviors demonstrated
- patient has violated the treatment agreement
Discontinuation is of pain medication often needs to be performed in a decreasing tapered fashion. This may be performed by reducing the opioid dose by 25% per week. Rapid decrease may cause withdrawal symptoms including:
- cramps
- diarrhea
- fast heartbeat
- sweating
- body aches
Withdrawal risks higher with longer treatment and higher doses.
Summary:
- controlled substance therapy should improve the patient's function and quality of life.
- Patient should not expect absolute relief from pain
- controlled substances will only be prescribed as long as the patient's function and pain continue to improve
- your physician can employ tools and tactics for safer and more effective controlled substance prescribing
- your provider can provide better patient care by following recommendations given by the Utah Department of Health and the the Federation of State medical boards of the United States.
Tanner Memorial Clinics
CONTROLLED SUBSTANCE AGREEMENT USING PRESCRIPTION OPIOIDS AND OTHER CONTROLLED SUBSTANCES (Adapted from the Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain)
PATIENT NAME:_______________________________________________________
PRESCRIBER NAME: Dr Gary N. Oaks DPM
THE PURPOSE OF THIS AGREEMENT IS TO STRUCTURE OUR PLAN TO WORK TOGETHER TO TREAT YOUR PAIN AND OTHER CONDITIONS REQUIRING CONTROLLED SUBSTANCES. THIS WILL PROTECT YOUR ACCESS TO OPIOID PAIN MEDICATIONS AND OUR ABILITY TO PRESCRIBE THEM TO YOU.
I (patient) understand the following:
____ Opioids/controlled substances have been prescribed to me on a trial basis. One of the goals of this treatment is to improve my ability to perform various functions, including return to work. If significant demonstrable improvement in my functional capabilities does not result from this trial of treatment, my prescriber may determine to end the trial. The goal is for improved function.
____ Opioids/controlled substances are being prescribed to make my pain/symptoms tolerable but may not cause it to disappear entirely. If this goal is not reached, my medical provider may end the trial. Goal for reduction of pain/symptoms.
____ Drowsiness and slowed reflexes can be a temporary side effect of opioids, especially during dosage adjustments. If I am experiencing drowsiness while taking opioids, I agree not to drive a vehicle nor perform other tasks that could involve danger to myself or others.
____ Using opioids to treat chronic pain will result in the development of physical dependence and sudden decreases or discontinuation of the medication will lead to symptoms of opioid withdrawal. These symptoms can include: runny nose, yawning, large pupils, goose bumps, abdominal pain and cramping, diarrhea, vomiting, irritability, depressed mood, aches and flu-like symptoms. I understand that opioid withdrawal is uncomfortable but not physically life threatening.
____ There is a small but significant risk that opioid psychological dependence (addiction) can occur. If it appears that I may be developing addiction, my medical provider may determine to end the trial.
____ The patient education as discussed above applies to all controlled substances, though usage and adverse effects (including dependence and addiction) of medications vary. Your medical provider will address other controlled substances if they are a part of your treatment program.
I agree to the following:
____ I agree to take medications as prescribed. Using medications at a faster rate or increased dose other than prescribed may result in death.
____ I agree to have regular office visits as decided by my medical provider. I understand that this agreement will be null and void if more than 15 days elapse past my anticipated, regular appointment time.
____ I agree to keep the prescribed medication in a safe and secure place, and that lost, damaged, or stolen medication will not be replaced.
____ I agree not to share, sell, or in any way provide my medication to any other person. ____ I agree to obtain prescription medication from one designated licensed pharmacist/pharmacy. I understand that my medical provider may check the Utah Controlled Substance Database at any time to check my compliance.
____ I agree not to seek or obtain ANY mood-modifying medication, including pain relievers or tranquilizers from ANY other prescriber without first discussing this with my prescriber. If a situation arises in which I have no alternative but to obtain my necessary prescription from another prescriber, I will advise that prescriber of this agreement. I will then immediately advise my prescriber that I obtained a prescription from another prescriber.
____ I agree to refrain from the use of ALL other mood-modifying drugs (prescription and illicit), including alcohol and marijuana. My medical provider may prescribe other controlled substances as part of my treatment plan.
____ I agree to submit to random urine or blood for drug testing at my prescriber’s request. I understand that it is my responsibility to pay for drug screening if self pay or it is not covered by insurance. I agree to have random pill counts at my prescriber’s request. I must have access to a telephone and able to be reached by telephone within 24 hours. Drug testing and pill counts verify compliance with my treatment plan. If I cannot produce urine or blood at the time requested, this will be grounds for termination of pain management services. I agree to being seen by an addiction specialist if requested.
____ I agree to attend and participate fully in any other assessments of pain treatment programs which may be recommended by the prescriber at any time. In consideration of my treatment goals, I agree to help myself by following better health habits, including exercise, smoking cessation, and weight control.
____ I agree to attend and participate fully in a mental health evaluation and/or treatment for mental health disorders (i.e. depression, anxiety, etc) as may be recommended by the prescriber at any time
____ I understand that this contract also applies to any and all controlled substances that are part of my total treatment program, not just limited to pain management.
____ I understand that ANY deviation from the above agreement will be grounds for termination of controlled substance prescribing and dismissal from this clinic.
____ I understand that by agreeing to evaluation and/or treatment by Dr. Gary N. Oaks DPM for any reason I am voluntarily and without reservation agreeing to any and all treatment policies listed above for the entire duration of my care regardless of "Patient Signature" or "Date". If I do not wish to agree to these policies I understand that I need to seek care elsewhere.
___________________________________________
Patient Signature
___________________________________________
Date
CONTROLLED SUBSTANCE AGREEMENT USING PRESCRIPTION OPIOIDS AND OTHER CONTROLLED SUBSTANCES (Adapted from the Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain)
PATIENT NAME:_______________________________________________________
PRESCRIBER NAME: Dr Gary N. Oaks DPM
THE PURPOSE OF THIS AGREEMENT IS TO STRUCTURE OUR PLAN TO WORK TOGETHER TO TREAT YOUR PAIN AND OTHER CONDITIONS REQUIRING CONTROLLED SUBSTANCES. THIS WILL PROTECT YOUR ACCESS TO OPIOID PAIN MEDICATIONS AND OUR ABILITY TO PRESCRIBE THEM TO YOU.
I (patient) understand the following:
____ Opioids/controlled substances have been prescribed to me on a trial basis. One of the goals of this treatment is to improve my ability to perform various functions, including return to work. If significant demonstrable improvement in my functional capabilities does not result from this trial of treatment, my prescriber may determine to end the trial. The goal is for improved function.
____ Opioids/controlled substances are being prescribed to make my pain/symptoms tolerable but may not cause it to disappear entirely. If this goal is not reached, my medical provider may end the trial. Goal for reduction of pain/symptoms.
____ Drowsiness and slowed reflexes can be a temporary side effect of opioids, especially during dosage adjustments. If I am experiencing drowsiness while taking opioids, I agree not to drive a vehicle nor perform other tasks that could involve danger to myself or others.
____ Using opioids to treat chronic pain will result in the development of physical dependence and sudden decreases or discontinuation of the medication will lead to symptoms of opioid withdrawal. These symptoms can include: runny nose, yawning, large pupils, goose bumps, abdominal pain and cramping, diarrhea, vomiting, irritability, depressed mood, aches and flu-like symptoms. I understand that opioid withdrawal is uncomfortable but not physically life threatening.
____ There is a small but significant risk that opioid psychological dependence (addiction) can occur. If it appears that I may be developing addiction, my medical provider may determine to end the trial.
____ The patient education as discussed above applies to all controlled substances, though usage and adverse effects (including dependence and addiction) of medications vary. Your medical provider will address other controlled substances if they are a part of your treatment program.
I agree to the following:
____ I agree to take medications as prescribed. Using medications at a faster rate or increased dose other than prescribed may result in death.
____ I agree to have regular office visits as decided by my medical provider. I understand that this agreement will be null and void if more than 15 days elapse past my anticipated, regular appointment time.
____ I agree to keep the prescribed medication in a safe and secure place, and that lost, damaged, or stolen medication will not be replaced.
____ I agree not to share, sell, or in any way provide my medication to any other person. ____ I agree to obtain prescription medication from one designated licensed pharmacist/pharmacy. I understand that my medical provider may check the Utah Controlled Substance Database at any time to check my compliance.
____ I agree not to seek or obtain ANY mood-modifying medication, including pain relievers or tranquilizers from ANY other prescriber without first discussing this with my prescriber. If a situation arises in which I have no alternative but to obtain my necessary prescription from another prescriber, I will advise that prescriber of this agreement. I will then immediately advise my prescriber that I obtained a prescription from another prescriber.
____ I agree to refrain from the use of ALL other mood-modifying drugs (prescription and illicit), including alcohol and marijuana. My medical provider may prescribe other controlled substances as part of my treatment plan.
____ I agree to submit to random urine or blood for drug testing at my prescriber’s request. I understand that it is my responsibility to pay for drug screening if self pay or it is not covered by insurance. I agree to have random pill counts at my prescriber’s request. I must have access to a telephone and able to be reached by telephone within 24 hours. Drug testing and pill counts verify compliance with my treatment plan. If I cannot produce urine or blood at the time requested, this will be grounds for termination of pain management services. I agree to being seen by an addiction specialist if requested.
____ I agree to attend and participate fully in any other assessments of pain treatment programs which may be recommended by the prescriber at any time. In consideration of my treatment goals, I agree to help myself by following better health habits, including exercise, smoking cessation, and weight control.
____ I agree to attend and participate fully in a mental health evaluation and/or treatment for mental health disorders (i.e. depression, anxiety, etc) as may be recommended by the prescriber at any time
____ I understand that this contract also applies to any and all controlled substances that are part of my total treatment program, not just limited to pain management.
____ I understand that ANY deviation from the above agreement will be grounds for termination of controlled substance prescribing and dismissal from this clinic.
____ I understand that by agreeing to evaluation and/or treatment by Dr. Gary N. Oaks DPM for any reason I am voluntarily and without reservation agreeing to any and all treatment policies listed above for the entire duration of my care regardless of "Patient Signature" or "Date". If I do not wish to agree to these policies I understand that I need to seek care elsewhere.
___________________________________________
Patient Signature
___________________________________________
Date
Controlled Substance Education Update 2018
Pain is defined as an unpleasant sensory or emotional experience. Pain is the most common cause patients seek medical care. Pain is a highly personal experience modified and amplified by past experience; immediate, psychological, physical, and social context; future expectations; cultural norms, and spiritual orientation. Pain often interferes with basic functioning including activities of sleep, social interaction, and enjoyment. This erodes the patient's quality of life to a meaningful extent. When pain is severe enough to interfere with usual activities or healing medical care should be sought with a valuation assessment and treatment plans focused at restoring the patient's optimal health with minimal harm. Timely evaluation and intervention are key in regards to the patient's reduction in pain and resolution of normal activities.
An expectation for no pain may be unreasonable and can lead to excessive risk.
Types of Pain
1-Biomedical
⦁ acute self-limiting injury or surgery.
⦁ cancer related
⦁ cancer treatment related
⦁ recurrent, chronic and progressive disease states (arthritis, spinal disease, myofascial pain, ischemic, G.I./GU disorders, neuropathic[
⦁ stroke , Parkinson's , Phantom pain, diabetes , peripheral vascular disease , chronic regional pain syndrome including some postoperative pain ], mixture intermediate pain including migraines , low back or neck pain , pelvic syndrome
2-Psychosocial/Spiritual
⦁ interpersonal conflict, or unresolved interpersonal issues
⦁ pain in addition to anxiety and depression reinforce each other as a complex interaction which often cannot be readily separated.
⦁ Sleep and mood changes, and disorders
The federal government and the division of occupational licensing for physicians for the state of Utah provide/mandates specific recommendations on the treating of pain with opioid/narcotics. The following will help you to understand what those recommendations are so that you can have the best functional outcomes.
(For further information, see the opioid prescribing guidelines and education project administrators, second edition – 2017, and the opioid prescribing guidelines advisory committee – second edition 2017, or the Utah medical Association foundation.)
The state of Utah currently ranks number seven in the United States in regards to the number of opioid -related deaths.
Your physicians overall goal is to do no harm and provide you the greatest benefit in clinical outcomes.
Because opioids and other medications, including sedatives, hypnotics, anti-anxiety medications, and psychological stimulants both prescribed and otherwise pose significant challenge because they can cause dependence, addiction, withdrawal, and potentially death.
Most common way that this occurs is respiratory depression (decreased stimulus for breathing). This is especially true when combined medications listed above, or recreational drugs such as over-the-counter sleep aids, alcohol, and recreational drugs are combined.
The most commonly abused narcotic is oxycodone (Percocet), followed by hydrocodone (Norco). While hydrocodone related deaths have reduced over the last four years oxycodone related deaths have increased.
Because each person has differing absorption, distribution, metabolism, and elimination rates. It may be difficult at times to know exactly how much medication may be right for you. Because of this recommendations have been provided.
For example, Tylenol (acetaminophen) is a commonly abused over-the-counter pain reliever. The Center for disease control (CDC) has recommended for low risk populations no more than 3 g (3000 milligrams) of Tylenol a day. If you have alcohol use greater than three alcoholic beverages a day, or known liver disease. This number should be reduced.
Reasons to not use a certain type of pain medication may include:
⦁ allergy, or history of sensitivity such as dysphoria
⦁ concurrent use of medications, such as pentazocine, butorphanol, nalbuphin, or other serotonin reactive medications (SSRI's).
⦁ Bowel related dysfunction
⦁ central nervous system depressing medications
⦁ or history of respiratory depression including sleep apnea
Reasons to change a pain medication include
⦁ intolerable adverse effects
⦁ poor efficacy
⦁ potential drug interactions
⦁ need for a different route of administration (such as rectally, or liquid medication)
⦁ change in clinical status, including concern for abuse or malabsorption syndrome.
Safe storage and disposal: patients need to be aware of their pain medication and keep all controlled substance under lock and key with the exception of next schedule medication dosage. Failure to do so or loss of pain medication will not be refilled or re-dispensed before the next scheduled dosage. Therefore less than optimal pain management may be experienced. No exceptions will be provided.
Disposal of excessive, unnecessary, or expired medications prevents accidental usage, especially by children or by diversion.
You can also check with your pharmacist. Some pharmacies have mail-back programs and disposal kiosks for unused medicines.
How to Dispose of Medicines at Home
There are two ways to dispose of medicine, depending on the drug.
Flushing medicines: Because some medicines could be especially harmful to others, they have specific directions to immediately flush them down the sink or toilet when they are no longer needed.
How will you know? Check the label or the patient information leaflet with your medicine. Or consult the U.S. Food and Drug Administration’s list of medicines recommended for disposal by flushing.
Disposing medicines in household trash: Almost all medicines can be thrown into your household trash. These include prescription and over-the-counter (OTC) drugs in pills, liquids, drops, patches, creams, and inhalers.
Follow these steps:
1. Remove the drugs from their original containers and mix them with something undesirable, such as used coffee grounds, dirt, or cat litter. This makes the medicine less appealing to children and pets and unrecognizable to someone who might intentionally go through the trash looking for drugs.
2. Put the mixture in something you can close (a re-sealable zipper storage bag, empty can, or other container) to prevent the drug from leaking or spilling out.
3. Throw the container in the garbage.
4. Scratch out all your personal information on the empty medicine packaging to protect your identity and privacy. Throw the packaging away.
If you have a question about your medicine, ask your health care provider or pharmacist.
Disposing of Fentanyl Patches
Some prescription drugs — such as powerful narcotic pain medicines and other controlled substances — have instructions for flushing to reduce the danger of overdose from unintentional or illegal use.
One example is the fentanyl patch. This adhesive patch delivers a strong pain medicine through the skin. Even after a patch is used, a lot of the medicine remains. That’s why the drug comes with instructions to flush used or leftover patches.
Disposing of Inhaler Products
One environmental concern involves inhalers used by people who have asthma or other breathing problems, such as chronic obstructive pulmonary disease. Read handling instructions on the labeling of inhalers and aerosol products. These products could be dangerous if punctured or thrown into a fire or incinerator. To properly dispose of these products and follow local regulations and laws, contact your trash and recycling facility.
Flushing Drugs and the Water Supply
Some people wonder if it’s okay to flush certain medicines. There are concerns about the small levels of drugs that may be found in surface water, such as rivers and lakes, and in drinking water supplies.
“The main way drug residues enter water systems is by people taking medicines and then naturally passing them through their bodies,” says Raanan Bloom, Ph.D., an environmental assessment expert at the FDA. “Many drugs are not completely absorbed or metabolized by the body and can enter the environment after passing through wastewater treatment plants.”
The FDA and the U.S. Environmental Protection Agency take the concerns of flushing certain medicines in the environment seriously. Still, there has been no sign of environmental effects caused by flushing recommended drugs.
(Reference: FDA.gov. https://www.fda.gov/forconsumers/consumerupdates/ucm101653.htm)
Driving and functional safety instructions: there is an adequate data in regards to definitive recommendations of types of activities that can be safely performed after taking pain medication. Each patient circumstances needs to be evaluated on their own merits. Patients should not drive during initial use of opioids or other CNS depressant medications until they know how this appropriately affects them.
Medications commonly used for acute pain (depending on need/function as determined by your doctor).
⦁ Tylenol (acetaminophen)
⦁ Nonsteroidal anti-inflammatories (NSAIDs). Examples include 17 different classes of pain relievers each which is metabolized differently. Therefore failure of one medication does not mean failure of others.
⦁ Hydrocodone (example Lortab, Lorcet, Norco, Vicodin)
⦁ Oxycodone (Percocet, OxyContin, Endocet, Roxicodone)
⦁ Codeine
⦁ Tramadol (example Ultram)
Other narcotic medications used usually to treat chronic pain include: morphine, hydromorphone, fentanyl, buprenorphine, and methadone.
There is a higher risk of opioid toxicity and adverse effects, particularly respiratory depression. When central nervous system depressants are combined with opioids, including benzodiazepines, muscle relaxants, sleep aids, and alcohol.
Treating acute pain for most could include the following regimen:
Tier 1:
⦁ protection
⦁ rest
⦁ ice
⦁ compression
⦁ elevation
⦁ Diet
⦁ weight loss
⦁ cooling and heating techniques such as contrast baths
⦁ sleeping hygiene
⦁ smoking cessation
⦁ aerobic and strengthening exercises (of non-injured area initially)
⦁ meditation and relaxing strategies
Tier 2
⦁ in addition to tier 1
⦁ cognitive behavioral therapy (CBT)
⦁ physical therapy (PT)
⦁ occupational therapy (OT)
⦁ massage therapy
⦁ music therapy
⦁ aromatherapy
⦁ acupuncture
⦁ yoga
⦁ transcutaneous electrical nerve stimulation (TENS)
⦁ topical therapy (bio freeze, deep blue, sports creams, bag balm, etc.)
Tier 3:
in addition to tier 1-2 treatments
⦁ nonsteroidal anti-inflammatories
⦁ prescription topical pain relievers
Tier 4:
in addition to tier 1 – 3 treatments
⦁ Time specified duration use of narcotic analgesics at the lowest effective dose, usually for breakthrough pain only.This means pain will be reduced , but not likely eliminated .
⦁ Neuropathic pain medications (gabapentin/Neurontin, Lyrica, Cymbalta, nortriptyline, amitriptyline etc.)
Tier 5:
⦁ referrals to appropriate pain management specialist
Most medicine specialties such as primary care physicians, internist's, podiatrists/orthopedic extremity specialists, dermatologist's, gastrointestinal, emergency medicine, etc. primarily function to treat acute (less than 90 days), musculoskeletal injuries resulting in pain and dysfunction.
Chronic pain management specialties are available to treat pain that is exceeding an extended course. These would include: rheumatology, pain management specialists (pain management clinics, orthopedic spine clinics, neurologists), mental health specialists, sociologists, and certain branches of physical and occupational and cognitive therapy.
When short-acting opioids are indicated for the treatment of acute pain notify your doctor if you have a history of acute opioid exposure within the last two years or at an early age, chronic pain management, history of substance abuse, psychiatric, or other physical health concerns, including but not limited to complex regional pain syndrome, fibromyalgia, restless leg syndrome, use of other addictive substances , whether illegal or not (marijuana, tobacco, alcohol, caffeine etc.). Failure to do so could result in adverse reactions, including loss of life, or discharge from the clinic.
Patients should securely store medications, not share with others, and dispose of pain medication properly. For further human resource go to www.useonlyasdirected.org
In order to prevent patient from advancing from acute to chronic pain appropriate timeliness in seeking medical attention, accurate reporting of pain and other associated signs and symptoms, and referral from an acute pain manager to a chronic pain manager/appropriate intervention is key. Factors that may affect chronic pain other than ongoing tissue damage or inflammatory disease may include
⦁ genetic factors
⦁ severe preoperative pain
⦁ and social/behavioral/spiritual modification (somatization, catastrophic behavior, poor sleep, unresolved litigation, marital/family strife, job dissatisfaction, personal beliefs
Respiratory depression is the most common cause of death due to narcotic use.
Signs of opioid overdose include
⦁ paleface, blue lips/fingernails
⦁ limp body
⦁ slow or no breathing
⦁ no response after physical stimulation (rub hard on the middle of the person's chest a.k.a. sternal rub)
⦁ pinpoint pupils
⦁ slow heart rate
⦁ low blood pressure
Naloxone is a medication available to reverse in short duration (30 – 90 minutes) the effects of narcotics. This can be made available by prescription from your provider or without prescription at the request to your local pharmacist. Additional information and patient materials can be found at naloxone.utah.gov
Other potential side effects of opioid use include addiction, dependence, withdrawal.
Five signs of controlled substance abuse include:
⦁ drowsiness or the lack of energy
⦁ inability to concentrate and lack of motivation
⦁ social, behavioral changes
⦁ changes in appearance
⦁ increased secrecy
Using the four C's of addiction is helpful way to identify potential signs:
⦁ control impaired
⦁ craving
⦁ compulsive use
⦁ continuation despite harm
Patients and their caregivers should be aware of the signs of overdose including:
⦁ episodic cessation of breathing
⦁ extreme drowsiness or difficulty awaking
⦁ trouble breathing or slow shallow breathing
⦁ fast or slow heartbeat or palpitations
⦁ dizziness
⦁ confusion
If an overdose is suspected, a sample guideline could include:
⦁ never induce vomiting or give anything by mouth unless advised by poison control/physician
⦁ call poison control 1 – 800 – 222 – 1222
⦁ administer naloxone as direct did if immediately available
⦁ call 911
The best way to prevent unintended overdose includes:
⦁ take medication as directed
⦁ take a the smallest amount necessary to address breakthrough pain not addressed by other lower risk alternatives.
⦁ Never share medication.
⦁ Guard medication under lock and key
⦁ dispose of unused medication appropriately.
If you have any further questions regarding this or other pain management/narcotic based questions. Please discuss this further with your physician.
Pain is defined as an unpleasant sensory or emotional experience. Pain is the most common cause patients seek medical care. Pain is a highly personal experience modified and amplified by past experience; immediate, psychological, physical, and social context; future expectations; cultural norms, and spiritual orientation. Pain often interferes with basic functioning including activities of sleep, social interaction, and enjoyment. This erodes the patient's quality of life to a meaningful extent. When pain is severe enough to interfere with usual activities or healing medical care should be sought with a valuation assessment and treatment plans focused at restoring the patient's optimal health with minimal harm. Timely evaluation and intervention are key in regards to the patient's reduction in pain and resolution of normal activities.
An expectation for no pain may be unreasonable and can lead to excessive risk.
Types of Pain
1-Biomedical
⦁ acute self-limiting injury or surgery.
⦁ cancer related
⦁ cancer treatment related
⦁ recurrent, chronic and progressive disease states (arthritis, spinal disease, myofascial pain, ischemic, G.I./GU disorders, neuropathic[
⦁ stroke , Parkinson's , Phantom pain, diabetes , peripheral vascular disease , chronic regional pain syndrome including some postoperative pain ], mixture intermediate pain including migraines , low back or neck pain , pelvic syndrome
2-Psychosocial/Spiritual
⦁ interpersonal conflict, or unresolved interpersonal issues
⦁ pain in addition to anxiety and depression reinforce each other as a complex interaction which often cannot be readily separated.
⦁ Sleep and mood changes, and disorders
The federal government and the division of occupational licensing for physicians for the state of Utah provide/mandates specific recommendations on the treating of pain with opioid/narcotics. The following will help you to understand what those recommendations are so that you can have the best functional outcomes.
(For further information, see the opioid prescribing guidelines and education project administrators, second edition – 2017, and the opioid prescribing guidelines advisory committee – second edition 2017, or the Utah medical Association foundation.)
The state of Utah currently ranks number seven in the United States in regards to the number of opioid -related deaths.
Your physicians overall goal is to do no harm and provide you the greatest benefit in clinical outcomes.
Because opioids and other medications, including sedatives, hypnotics, anti-anxiety medications, and psychological stimulants both prescribed and otherwise pose significant challenge because they can cause dependence, addiction, withdrawal, and potentially death.
Most common way that this occurs is respiratory depression (decreased stimulus for breathing). This is especially true when combined medications listed above, or recreational drugs such as over-the-counter sleep aids, alcohol, and recreational drugs are combined.
The most commonly abused narcotic is oxycodone (Percocet), followed by hydrocodone (Norco). While hydrocodone related deaths have reduced over the last four years oxycodone related deaths have increased.
Because each person has differing absorption, distribution, metabolism, and elimination rates. It may be difficult at times to know exactly how much medication may be right for you. Because of this recommendations have been provided.
For example, Tylenol (acetaminophen) is a commonly abused over-the-counter pain reliever. The Center for disease control (CDC) has recommended for low risk populations no more than 3 g (3000 milligrams) of Tylenol a day. If you have alcohol use greater than three alcoholic beverages a day, or known liver disease. This number should be reduced.
Reasons to not use a certain type of pain medication may include:
⦁ allergy, or history of sensitivity such as dysphoria
⦁ concurrent use of medications, such as pentazocine, butorphanol, nalbuphin, or other serotonin reactive medications (SSRI's).
⦁ Bowel related dysfunction
⦁ central nervous system depressing medications
⦁ or history of respiratory depression including sleep apnea
Reasons to change a pain medication include
⦁ intolerable adverse effects
⦁ poor efficacy
⦁ potential drug interactions
⦁ need for a different route of administration (such as rectally, or liquid medication)
⦁ change in clinical status, including concern for abuse or malabsorption syndrome.
Safe storage and disposal: patients need to be aware of their pain medication and keep all controlled substance under lock and key with the exception of next schedule medication dosage. Failure to do so or loss of pain medication will not be refilled or re-dispensed before the next scheduled dosage. Therefore less than optimal pain management may be experienced. No exceptions will be provided.
Disposal of excessive, unnecessary, or expired medications prevents accidental usage, especially by children or by diversion.
You can also check with your pharmacist. Some pharmacies have mail-back programs and disposal kiosks for unused medicines.
How to Dispose of Medicines at Home
There are two ways to dispose of medicine, depending on the drug.
Flushing medicines: Because some medicines could be especially harmful to others, they have specific directions to immediately flush them down the sink or toilet when they are no longer needed.
How will you know? Check the label or the patient information leaflet with your medicine. Or consult the U.S. Food and Drug Administration’s list of medicines recommended for disposal by flushing.
Disposing medicines in household trash: Almost all medicines can be thrown into your household trash. These include prescription and over-the-counter (OTC) drugs in pills, liquids, drops, patches, creams, and inhalers.
Follow these steps:
1. Remove the drugs from their original containers and mix them with something undesirable, such as used coffee grounds, dirt, or cat litter. This makes the medicine less appealing to children and pets and unrecognizable to someone who might intentionally go through the trash looking for drugs.
2. Put the mixture in something you can close (a re-sealable zipper storage bag, empty can, or other container) to prevent the drug from leaking or spilling out.
3. Throw the container in the garbage.
4. Scratch out all your personal information on the empty medicine packaging to protect your identity and privacy. Throw the packaging away.
If you have a question about your medicine, ask your health care provider or pharmacist.
Disposing of Fentanyl Patches
Some prescription drugs — such as powerful narcotic pain medicines and other controlled substances — have instructions for flushing to reduce the danger of overdose from unintentional or illegal use.
One example is the fentanyl patch. This adhesive patch delivers a strong pain medicine through the skin. Even after a patch is used, a lot of the medicine remains. That’s why the drug comes with instructions to flush used or leftover patches.
Disposing of Inhaler Products
One environmental concern involves inhalers used by people who have asthma or other breathing problems, such as chronic obstructive pulmonary disease. Read handling instructions on the labeling of inhalers and aerosol products. These products could be dangerous if punctured or thrown into a fire or incinerator. To properly dispose of these products and follow local regulations and laws, contact your trash and recycling facility.
Flushing Drugs and the Water Supply
Some people wonder if it’s okay to flush certain medicines. There are concerns about the small levels of drugs that may be found in surface water, such as rivers and lakes, and in drinking water supplies.
“The main way drug residues enter water systems is by people taking medicines and then naturally passing them through their bodies,” says Raanan Bloom, Ph.D., an environmental assessment expert at the FDA. “Many drugs are not completely absorbed or metabolized by the body and can enter the environment after passing through wastewater treatment plants.”
The FDA and the U.S. Environmental Protection Agency take the concerns of flushing certain medicines in the environment seriously. Still, there has been no sign of environmental effects caused by flushing recommended drugs.
(Reference: FDA.gov. https://www.fda.gov/forconsumers/consumerupdates/ucm101653.htm)
Driving and functional safety instructions: there is an adequate data in regards to definitive recommendations of types of activities that can be safely performed after taking pain medication. Each patient circumstances needs to be evaluated on their own merits. Patients should not drive during initial use of opioids or other CNS depressant medications until they know how this appropriately affects them.
Medications commonly used for acute pain (depending on need/function as determined by your doctor).
⦁ Tylenol (acetaminophen)
⦁ Nonsteroidal anti-inflammatories (NSAIDs). Examples include 17 different classes of pain relievers each which is metabolized differently. Therefore failure of one medication does not mean failure of others.
⦁ Hydrocodone (example Lortab, Lorcet, Norco, Vicodin)
⦁ Oxycodone (Percocet, OxyContin, Endocet, Roxicodone)
⦁ Codeine
⦁ Tramadol (example Ultram)
Other narcotic medications used usually to treat chronic pain include: morphine, hydromorphone, fentanyl, buprenorphine, and methadone.
There is a higher risk of opioid toxicity and adverse effects, particularly respiratory depression. When central nervous system depressants are combined with opioids, including benzodiazepines, muscle relaxants, sleep aids, and alcohol.
Treating acute pain for most could include the following regimen:
Tier 1:
⦁ protection
⦁ rest
⦁ ice
⦁ compression
⦁ elevation
⦁ Diet
⦁ weight loss
⦁ cooling and heating techniques such as contrast baths
⦁ sleeping hygiene
⦁ smoking cessation
⦁ aerobic and strengthening exercises (of non-injured area initially)
⦁ meditation and relaxing strategies
Tier 2
⦁ in addition to tier 1
⦁ cognitive behavioral therapy (CBT)
⦁ physical therapy (PT)
⦁ occupational therapy (OT)
⦁ massage therapy
⦁ music therapy
⦁ aromatherapy
⦁ acupuncture
⦁ yoga
⦁ transcutaneous electrical nerve stimulation (TENS)
⦁ topical therapy (bio freeze, deep blue, sports creams, bag balm, etc.)
Tier 3:
in addition to tier 1-2 treatments
⦁ nonsteroidal anti-inflammatories
⦁ prescription topical pain relievers
Tier 4:
in addition to tier 1 – 3 treatments
⦁ Time specified duration use of narcotic analgesics at the lowest effective dose, usually for breakthrough pain only.This means pain will be reduced , but not likely eliminated .
⦁ Neuropathic pain medications (gabapentin/Neurontin, Lyrica, Cymbalta, nortriptyline, amitriptyline etc.)
Tier 5:
⦁ referrals to appropriate pain management specialist
Most medicine specialties such as primary care physicians, internist's, podiatrists/orthopedic extremity specialists, dermatologist's, gastrointestinal, emergency medicine, etc. primarily function to treat acute (less than 90 days), musculoskeletal injuries resulting in pain and dysfunction.
Chronic pain management specialties are available to treat pain that is exceeding an extended course. These would include: rheumatology, pain management specialists (pain management clinics, orthopedic spine clinics, neurologists), mental health specialists, sociologists, and certain branches of physical and occupational and cognitive therapy.
When short-acting opioids are indicated for the treatment of acute pain notify your doctor if you have a history of acute opioid exposure within the last two years or at an early age, chronic pain management, history of substance abuse, psychiatric, or other physical health concerns, including but not limited to complex regional pain syndrome, fibromyalgia, restless leg syndrome, use of other addictive substances , whether illegal or not (marijuana, tobacco, alcohol, caffeine etc.). Failure to do so could result in adverse reactions, including loss of life, or discharge from the clinic.
Patients should securely store medications, not share with others, and dispose of pain medication properly. For further human resource go to www.useonlyasdirected.org
In order to prevent patient from advancing from acute to chronic pain appropriate timeliness in seeking medical attention, accurate reporting of pain and other associated signs and symptoms, and referral from an acute pain manager to a chronic pain manager/appropriate intervention is key. Factors that may affect chronic pain other than ongoing tissue damage or inflammatory disease may include
⦁ genetic factors
⦁ severe preoperative pain
⦁ and social/behavioral/spiritual modification (somatization, catastrophic behavior, poor sleep, unresolved litigation, marital/family strife, job dissatisfaction, personal beliefs
Respiratory depression is the most common cause of death due to narcotic use.
Signs of opioid overdose include
⦁ paleface, blue lips/fingernails
⦁ limp body
⦁ slow or no breathing
⦁ no response after physical stimulation (rub hard on the middle of the person's chest a.k.a. sternal rub)
⦁ pinpoint pupils
⦁ slow heart rate
⦁ low blood pressure
Naloxone is a medication available to reverse in short duration (30 – 90 minutes) the effects of narcotics. This can be made available by prescription from your provider or without prescription at the request to your local pharmacist. Additional information and patient materials can be found at naloxone.utah.gov
Other potential side effects of opioid use include addiction, dependence, withdrawal.
Five signs of controlled substance abuse include:
⦁ drowsiness or the lack of energy
⦁ inability to concentrate and lack of motivation
⦁ social, behavioral changes
⦁ changes in appearance
⦁ increased secrecy
Using the four C's of addiction is helpful way to identify potential signs:
⦁ control impaired
⦁ craving
⦁ compulsive use
⦁ continuation despite harm
Patients and their caregivers should be aware of the signs of overdose including:
⦁ episodic cessation of breathing
⦁ extreme drowsiness or difficulty awaking
⦁ trouble breathing or slow shallow breathing
⦁ fast or slow heartbeat or palpitations
⦁ dizziness
⦁ confusion
If an overdose is suspected, a sample guideline could include:
⦁ never induce vomiting or give anything by mouth unless advised by poison control/physician
⦁ call poison control 1 – 800 – 222 – 1222
⦁ administer naloxone as direct did if immediately available
⦁ call 911
The best way to prevent unintended overdose includes:
⦁ take medication as directed
⦁ take a the smallest amount necessary to address breakthrough pain not addressed by other lower risk alternatives.
⦁ Never share medication.
⦁ Guard medication under lock and key
⦁ dispose of unused medication appropriately.
If you have any further questions regarding this or other pain management/narcotic based questions. Please discuss this further with your physician.
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